Major Medical Expenses - Budget Plan

All Major Medical Expenses are subject to pre-authorisation. Please call 0860 467 374.

PRO RATA BENFITS

Benefit limits are usually allocated in calendar-year cycles (from 1 January to 31 December) and is only applicable to the current year. Most benefits follow a one-year cycle.
Benefit limits will be adjusted on a pro rata basis should a member join during the year.

Ex gratia and additional benefits
info As an employer-based restricted medical scheme, Imperial Motus Med can lawfully grant ex gratia payments to its members. Ex gratia payments are defined as payments in addition to the registered rules and benefits of the Scheme and for purposes of clarity, Imperial Motus Med will make a distinction between ex gratia payments and additional benefits.

info Ex gratia payments and additional benefits

  • Ex Gratia Payments

    Ex gratia payments will only be granted in cases where the Employer agree to pay 60% of the agreed ex gratia payment, while the Scheme will pay 40% of the agreed ex gratia payment. The following principles will be followed:

    • Day-to-Day benefits where the annual limit is not sufficient, could qualify for ex gratia payments;
    • Any other benefits where the opinion received from the Scheme's Managed Care Provider indicate that the care or level of care is not clinically appropriate from a cost efficiency point of view, taking into account clinical outcomes and cost; and
    • The determination of the value of ex gratia payments will always be calculated at Scheme Rate.
  • Additional Benefits

    Additional benefits will be funded by the Scheme and no Employer involvement or contribution will be required, but additional benefits will only be granted where a Clinical Opinion from the Scheme's Managed Care Provider indicate that the care or level of care is clinically appropriate from a cost efficiency point of view, taking into account clinical outcomes and cost. The following principles will be followed:

    • Major Medical benefits where there is a shortfall, could qualify for additional benefits;
    • Additional benefits will always be paid at Scheme Rate.
Imperial Motus Med Health Plan
Imperial Motus Med Budget Plan

  • 1Hospitalisation - Private and Provincial
    a Accommodation in general ward, recovery room, intensive care unit or high care ward

    info Subject to pre-authorisation (0860 467 374)

    100%
    of Medical Scheme Rate
    b Theatre fees

    info Subject to pre-authorisation (0860 467 374)

    100%
    of Medical Scheme Rate
    c Medicines used in hospital/theatre

    info Subject to pre-authorisation (0860 467 374)

    100%
    of Medicine Price
    d A deductible of R1 000 applies if the following procedures are done in hospital:
    - Scopes
    - Arthroscopies
    - Gastro-intestinal endoscopies
        • Gastroscopies
        • Colonoscopies
        • Sigmoidoscopies
    - Urological scopes and cystoscopies
    - Gynaecological scopes
    - Biopsies
    - Minor dermatological procedures
    - Dental Procedures: Refer to dental benefit for more details on in-hospital dentistry (item 19 of Major Medical Expenses)
    - Nail surgeries
    - Minor skin lesions
    - Vasectomies
    - Conservative neck and back procedures
    - Circumcisions
    100%
    of Medical Scheme Rate.
    A deductible will not apply if done in doctor's rooms. Services in rooms will be paid at 100% of Medical Scheme Rate, except for dental procedures, which are still paid from day-to-day dental benefit
    e Circumcision

    Deductible applies, see 1a) above

    info R2 420 per beneficiary per annum
          Subject to pre-authorisation (0860 467 374)

    100%
    of Medical Scheme Rate
    fDental Procedures

    info Subject to pre-authorisation (0860 467 374)

    100%
    of Medical Scheme Rate.
    • Dental benefits which can be done in the dentist's room will have a deductible of R1000 if done in hospital.
    • If done in the dentist's room, the payment will still be in accordance with the day-to-day limits and only at 85%
  • 2Post-operational physiotherapy
    Physiotherapy after hip, knee and shoulder replacement surgery and spinal surgery only. Physiotherapy treatment after any other procedure will be paid from the Day-to-Day physiotherapy benefit limit.

    info 6 weeks' treatment, as per clinical protocols
          Subject to pre-authorisation (0860 467 674)

    100%
    of Medical Scheme Rate
  • 3GPs and Specialists in hospital
    a Visits and consultations

    info Subject to pre-authorisation (0860 467 374)

    100%
    of Medical Scheme Rate
    b Surgical procedures and anaesthetics

    info Subject to pre-authorisation (0860 467 374)

    100%
    of Medical Scheme Rate
  • 4Diagnostic Services
    infoPre-authorisation required for certain services
    a Radiology (X-rays) and pathology (in hospital)

    Member family limit calculated as follows:

    info R11 790 (MRI, CT or radio-isotope) per beneficiary per annum
          Subject to pre-authorisation (0860 467 374)

    100%
    of Medical Scheme Rate
    b Ultrasound scans (in and out of hospital)

    infoR1 900 per beneficiary per annum

    100%
    of Medical Scheme Rate
    c PET scans (in and out of hospital)

    not_interested No Benefit

    d Sleep studies, diagnostic polysomnograms (in and out of hospital)

    not_interested No Benefit

  • 5To-take-out (TTO) Medicine

    Medicines dispensed on discharge from hospital will be covered under the Major Medical Expenses

    info Subject to R520 per beneficiary per admission

    100%
    of Medicine Price
  • 6Out-patient Services
    Private and provincial hospitals
      • If the ICD-10 code is for an emergency (indicating that it is a prescribed minimum benefit), the cost of the consultation, facility, procedure, related materials and medication is to be paid at 100% of cost from the Major Medical Expenses.
      • If the ICD-10 code is not for an emergency (indicating that it is not a prescribed minimum benefit), the cost of the consultation, facility, procedure, related materials and medication is to be paid at 85% of Scheme Rate from the applicable day-to-day benefit limits.
      • The ICD-10 code is used to determine whether it is an emergency or non-emergency.
    Emergencies are classified as prescribed minimum benefits and has to be covered in full.
    100%
    of Cost from Major Medical Expenses for an emergency
    85%
    of Scheme Rate for non-emergency

    info Emergency Medical Condition

    • An emergency medical condition means the sudden onset of a health condition that requires immediate medical treatment and/or an operation. If the treatment is not available, the emergency could result in weakened bodily functions, serious and lasting damage to organs, limbs or other body parts, or even death.

  • 7Blood Transfusions

    info Subject to PMBs
          Subject to pre-authorisation (0860 467 374)

    100%
    of Cost
  • 8Nursing Services, Sub-acute Care and Hospice Services, including medicines, dressings, ointments, etc

    not_interested No Benefit

  • 9Ambulance Services

    info R5 360 per beneficiary per annum
          Subject to approval and pre-authorisation by preferred provider, Europ Assistance (0861 737 283)
          Emergency air ambulance not subject to the above limit, subject to Scheme approval

    100%
    of Cost
  • 10Internal Prostheses
    infoIncluding all accompanying temporary or permanent devices used to assist with the guidance, alignment or delivery of these internal prostheses and devices
    infoPatients may obtain pre-authorisation 10 (ten) working days prior to admission for a joint replacement or spinal fusion operation

    infoLimited to R43 800 per family per annum for prostheses
          Subject to pre-authorisation (0860 467 374)

    100%
    of Cost
    PMBs not subject to applicable limit
    Non-PMBs subject to applicable limit
  • 11Renal Dialysis
    infoInclusive of all related costs

    Benefit is subject to the submission of a treatment plan by the treating Specialist to the specialist care coach and approval of the treatment plan before treatment starts

    info Subject to pre-authorisation (0860 467 374)

    100%
    of the Negotiated Rate and PMBs
  • 12Organ Transplants
    a Hospital accommodation and surgically related services and procedures

    info Subject to Pre-authorisation (0860 467 374)
          PMBs covered in full, i.e. heart, kidneys and liver
          Non-PMBs covered at Medical Scheme Rate, i.e. other organs

    100%
    of the Negotiated Rate
    b Heart, kidneys and liver

    Including organ search (nationally only), harvesting and transportation. The benefit covers the donor if the recipient is an Imperial Motus Med member

    info Subject to pre-authorisation (0860 467 374)
          Unlimited
          

    100%
    of Cost
    c Corneal transplant

    Including organ search (nationally only)

    info Subject to pre-authorisation (0860 467 374)
          R35 050 per beneficiary per event

    100%
    of Cost
    d Other organs

    Including organ search (nationally only), harvesting and transportation. The benefit covers the cost of the donor if the recipient is an Imperial Motus Med member

    info Subject to pre-authorisation (0860 467 374)
          Limited to R12 310 for organs from a cadaver
          or limited to R39 430 for live donor organ(s) per beneficiary per annum

    100%
    of Medical Scheme Rate
    e Anti-rejection drugs

    info Subject to pre-authorisation (0860 467 374)

    100%
    of Medicine Price
  • 13HIV and AIDS
    All consultations, pathology and medicine related to diagnoses and treatment of the disease

    Subject to Pre-authorisation (0861 888 300) and clinical guidelines and protocols.

    HIV resistance tests provided only if pre-authorised by a relevant specialist care coach on the YourLife Programme.
    Polymerase chain reaction funded from Major Medical Expenses for babies 18 months and younger where the diagnosis relates to HIV testing.

    Medicine subject to Mediscor Reference Price.

    Members are encouraged to make use of the Scheme's Preferred Provider Pharmacies.

    100%
    of Cost, unlimited
  • 14Maternity Benefits
    a Labour and ward accommodation

    Normal delivery limited to three days
    Additional days are subject to submission of a motivation by the attending doctor and approval by the specialist care coach

    info Subject to pre-authorisation (0860 467 374)

    100%
    of Cost

    Elective caesarean delivery limited to four days
    Additional days are subject to submission of a motivation by the attending doctor and approval by the specialist care coach

    info Subject to pre-authorisation (0860 467 374)

    100%
    of Medical Scheme Rate (MSR)
    b Midwife

    Delivery by a midwife, confinement in a registered birthing unit or home delivery, including birth attendant and birth bath
    Midwife must be registered with the Board of Healthcare Funders and Nursing Council
    If a gynaecologist is not used, benefit covers pre- and post-confinement costs

    a Subject to pre-authorisation (0860 467 374)
          Four post-natal consultations with a midwife per event

    100%
    of Medical Scheme Rate
    cBenefits listed below are subject to enrolment on the Maternity Programme; if not registered on the Maternity Programme, benefits c1, c2, c3 and c4 are to be paid from day-to-day limits
    c1 Antenatal classes

    info R1 330 per beneficiary per annum
     If not registered on the maternity programme, this will be paid from the day-to-day limits

    100%
    of Cost, subject to pre-authorisation and registration on the Maternity Programme
    c2 Ultrasound scans during pregnancy

    Two 2D or 3D or 4D scans per pregnancy, up to 100% of the 2D scan at Medical Scheme Rate
    If not registered on the maternity programme, this will be paid from the day-to-day limits

    100%
    of Cost, subject to pre-authorisation and registration on the Maternity Programme
    c3 Antenatal vitamins during pregnancy

    infoR150 per month
     If not registered on the maternity programme, this will be paid from the day-to-day limits

    100%
    of Cost, subject to pre-authorisation and registration on the Maternity Programme
    c4Gynaecologist consultations during pregnancy (as per treatment plan)
    100%
    of Cost, subject to pre-authorisation and registration on the Maternity Programme
  • 15Rehabilitation
    infoThe benefit covers beneficiaries who are acutely disabled as a result of strokes, spinal cord injuries or brain injuries.
    infoThe condition must be non-progressive.
    infoAll associated accounts will be paid subject to this limit.

    infoPMBs only
           Subject to clinical protocols

    100%
    of Cost
  • 16Psychiatric Institutions and Substance and Alcohol Abuse

    infoMaximum of 21 days per beneficiary per annum
          Subject to pre-authorisation (0860 467 374)

    100%
    of Medical Scheme Rate
  • 17Stoma Care Products

    info Subject to pre-authorisation (0860 467 374)

    100%
    of Medical Scheme Rate
  • 18Cochlear Implants

    not_interested No Benefit

  • 19Dentistry
    a Dental alveolar surgery

    Surgical procedures involving the teeth and supporting jawbone ridges, such as:
    - Basic dental procedures in children under the age of eight
    - Surgical dental procedures in exceptional clinical scenarios in children older than eight and adults
        • Surgical removal of multiple/impacted teeth or roots
        • Apicectomies
        • Tooth exposures
        • Corticotomies
        • Surgical preparation of mouth for dentures, etc.
        • Wisdom teeth

    infoSubject to pre-authorisation (0860 467 374)

    100%
    of Medical Scheme Rate for hospitalisation, operating theatre, sedationist and anaesthetist's fee
    Note that the associated dental procedures will still be funded at
    85% of the Medical Scheme Rate from the respective Dental Benefit categories and sub-limits, as indicated under day-to-day benefits
    b Orthodontic-related surgery

    not_interested No Benefit

    c Maxillofacial surgery

    - Oral/facial trauma, such as fractured jaw or facial bones for which hospitalisation is required
    - Oral cancer and similar aggressive oral pathologies
    - Cleft lip/Palate repair
    - Salivary gland pathology
    - Serious life-threatening infection of dental origin
    - Internal temperomandibular joint (jaw-joint) pathology

    info Subject to pre-authorisation (0860 467 374)

    100%
    of Medical Scheme Rate for surgical procedures and related hospitalisation
  • 20Excimer Laser, Radial Keratotomy, Holmium Procedures, LASIK, Phakic lenses and intra-stromal rings (surgically related services and procedures)

    not_interested No Benefit

  • 21Breast Reduction, Mammoplasty and other cosmetic surgery if deemed clinically appropriate

    not_interested No Benefit

  • 22Prosthetic Limbs and Eyes

    Subject to the Internal Prosthesis limit in point 10 above

    Limited to R43 800 per family per annum

    infoSubject to pre-authorisation (0860 467 374)

    The submission of a quotation prior to purchase is required
    Benefit is available every two to five years as per clinical protocols

    100%
    of Cost
  • 23Infertility
    infoBenefit limited to the treatment guidelines applied by State hospitals

    Limited to PMBs only
    infoSubject to pre-authorisation (0860 467 374)

    100%
    of Cost
  • 24Oncology
    a Treatment

    Subject to a treatment plan and enrolment on the Oncology Programme

    infoOverall Oncology limit of R116 710 per beneficiary per annum
          Subject to pre-authorisation (0860 467 374)

    100%
    of Medical Scheme Rate
    if non-PMB;
    b Brachytherapy materials

    Including seeds and disposables and equipment

    infoLimited to R14 150 per beneficiary per annum and included in the Overall Oncology limit
          Subject to pre-authorisation (0860 467 374)

    100%
    of Medical Scheme Rate
    if non-PMB;
    c Pathology, X-rays, MRI, CT and radio-isotope scans

    infoLimit of R11 250 per beneficiary per annum
          Subject to pre-authorisation (0860 467 374)
          Not subject to the Overall Oncology limit

    100%
    of Medical Scheme Rate
    if non-PMB;
    d Oncology medicine

    infoSubject to R116 710 Overall Oncology limit
          Subject to pre-authorisation (0860 467 374)

    100%
    of Mediscor Reference Pricing (MRP)
  • 25Services Rendered Abroad by a foreign supplier

    not_interested No Benefit

  • 26Home Oxygen cylinders, concentrators and ventilation expenses

    infoPMBs only
          Subject to pre-authorisation (0860 467 374)

    100%
    of Cost
  • 27External Medical Appliances
    Permanent or temporary devices that are not surgically implanted

    Seen to improve the function of a diseased organ, e.g. wheelchair, crutches, CPAP machine, Baumanometer and all orthopaedic braces. Incontinence diapers, which are required as part of a chronic condition, are included

    infoR4 370 per beneficiary per annum
          Motivation required for devices and appliances above R1000
          (Two-year cycle applies to Blood Pressure Monitors, Glucometers, and Nebulisers only)
          Subject to pre-authorisation (0860 467 374)

    100%
    of Cost
  • 28Hearing Aids

    not_interested No Benefit

  • 29Prescribed Medicines
    Chronic medicine

    Prescribed for PMB and/or additional chronic conditions
    According to chronic medicine formulary only
    25% co-payment applies when using a non-formulary medicine

    infoUnlimited - PMBs only
          Pre-authorisation required

    You have to register your chronic medication with the Scheme by either completing the chronic medication application form or your treating doctor can contact the Chronic Medicine Management Team.

    100%
    of Mediscor Reference Price (MRP)